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Cryotherapy as comfort measure for magnesium sulfate administration.


Preeclampsia is a disorder where hypertension arises in pregnancy that can endanger the life of the mother and the baby. The global incidence of preeclampsia has been estimated at 5-14% of all pregnancies. In developing countries, hypertensive disorders were the second most common obstetrical cause of stillbirths and early neonatal deaths, accounting for 23.6% (Semenovskaya, 2010). In severe preeclampsia, blood pressures rise higher than 160 mmHg systole and 110 mmHg diastole, accompanied by proteinuria and edema. With no proper management, the disease may progress and seizures and total organ failure may occur which are very life-threatening. This is referred to as eclampsia. As preventive measure for the development of seizures, preeclampsia women are given Magnesium sulfate.

Magnesium sulfate is the drug of choice for preventing and treating seizures in postpartum clients who have severe preeclampsia. Magnesium sulfate is administered by the intravenous or intramuscular routes as an electrolyte replenisher, anticonvulsant and muscle relaxant (Greene, 2003).

As experienced by the current researchers, almost all of the patients receiving Magnesium sulfate in Ward I (Obstetrics Ward) of Vicente Sotto Memorial Medical Center in Cebu City, Philippines complained of pain especially after their first intramuscular medication. The initial cause of injection pain that may be experienced is the fact that an intramuscular injection itself is an invasive procedure, in that the body's natural barrier of skin is being penetrated. When a new muscular site is invaded and a volume of substance is injected therein, there is often some soreness associated with such an injection. The muscle group is not used to containing an additional volume of a substance, thus pain can result. As nursing students who had their related learning experience in that area last August 16-20, 2010, the researchers were instructed by the nurse-on-duty to place ice packs on the injection site (gluteal muscle) before and after every magnesium sulfate administration. This created the interest to study the effectiveness of cryotherapy as comfort measure for magnesium sulfate administration.

The primary aim of this study is to determine the effectiveness of cryotherapy as comfort measure for the pain brought about by intramuscular injection of Magnesium sulfate. Ice pack application may then become part of the nursing responsibilities for Magnesium sulfate administration provided that there is no significant alteration in drug efficacy.

This study was anchored on the Gate Control Theory introduced by psychologist Ronald Melzack and anatomist Patrick Wall (1978). They suggested that there is a "gating system" in the central nervous system that opens and closes to let pain messages through to the brain or to block them. According to the gate control theory of pain, a person's thoughts, beliefs, and emotions may affect how much pain we feel from a given physical sensation. The fundamental basis for this theory is the belief that psychological as well as physical factors guide the brain's interpretation of painful sensations and the subsequent response. One of these factors is counter stimulation in which ice pack application is used (, 2007).

Ice pack application diverts pain perception on the response to cold stimulation. Sensory messages travel from stimulated nerves to the spinal cord, the body's pain highway. There, they are reprocessed and sent through open gates to the thalamus, the brain's depot for tactile information. Once the nerve signal reaches the brain, the sensory information is processed in the context of the individual's current mood, state of attention, and prior experience. The integration of all these information influences the perception and experience of pain, and guides the individual's response (, 2007).


Magnesium sulfate is an anticonvulsant drug indicated to pre-eclamptic patients to prevent seizures and is usually given via intravenous (IV) or intramuscular injections (Euser and Cipolla, 2009).

In an article in (July, 2008) titled "A Guide to Post-Injection Muscular Pain", the main causes of localized muscular pain, tenderness and soreness that are experienced as a result of intramuscular (IM) injections were discussed. There is pain due to route of administration, mainly the invasiveness of injection wherein the body's natural barrier of skin is being penetrated by a sharp needle and any further cellular content along the needle's path is being sheared. This in itself, although relatively invasive, can cause some pain. This pain tends to be initial, however due to the design of sterile needles for injection, the curved nature of the needle point allows for minimal pain, and thus this is not a common cause of post-injection pain. Physical location of injection can also be considered a factor in the resulting discomfort after administration. The volume of injection will also make a significant difference to any soreness and pain experienced. Generally larger volumes are better tolerated in larger muscle groups (gluteus, quadriceps, etc), with smaller muscle groups (biceps, triceps, etc) fair better with smaller volumes (<2ml). As the volume injected is increased, the amount of substance normally present within the muscle is increased risking an inflammatory response and soreness.

Magnesium sulfate intramuscular injections have been reported as painful by patients undergoing the said therapy. Measures to alleviate the discomfort caused by the administration of this drug are continuously being identified, one of which is cryotherapy.

Ice pack use (cryotherapy) has been widely acknowledged in the medical field. It is currently prescribed in various therapies and results have shown beneficial to the clients. To further improve and expand its application in medicine, several researches have been conducted and some already underway.

In one related study, Martinez (2008) Research Scientist of Parker College of Chiropractic Research Institute, stated that cold application (cryotherapy) is the simplest and most commonly used method for treatment of acute musculoskeletal injury. Among chiropractic practitioners it is the most often utilized (94.5%) passive adjunctive therapy.

The physiological effects of cold have been well documented. Studies have shown that cold applications can reduce the metabolic rate of a tissue, decrease pain and swelling, and reduce muscle spasm. Most health care practitioners are taught to use ice therapy for treatment of bruises, strains, sprains, or muscle tears and most are familiar with the rest, ice, compression, and elevation (RICE) principle following acute soft tissue injury, yet there is little agreement in the literature on the optimum application technique for such care (Zeigler, 2010).

Hubbard and Denegar (2004) also showed that cryotherapy seems to be effective in decreasing pain. "The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury."

According to Taylor (2002) in her article IceTherapy (Cryotherapy), cryotherapy has historically been used to provide pain relief, reduce fever, slow the damage of thermal burns, control bleeding, and prevent or reduce edema caused by soft tissue trauma.

Kalyani Premkumar (2004), in his book entitled, The Massage Connection: Anatomy and Physiology, quoted Yurtkuran M. Kocagil by saying that "Ice massage or immersion, applied using specific techniques, is especially helpful in pain relief and, thereby, introduction of early mobilization exercises. Thus, Premkumar concluded that, "Massage prior to mobilization is very useful." In addition, Waldman (2009) in his book, Atlas of Interventional Pain Management, declared that injection of contrast dye with or without steroid should be discontinued if the patient complains of any significant pain on injection. Transient mild pressure paresthesia is often noted. Waldman showed that there is a way to prevent such occurrence to take place. He added that, "After the needle is removed, the ice pack is placed on the injection site to decrease postblock bleeding and pain."

Independent nursing actions fall within the scope of nursing practice and include controlling the environment, giving emotional support, and providing comfort. Comfort measures include applications of cold as an effective pain-relieving measure when used appropriately. Cold decreases blood flow, edema, and inflammation and may decrease muscle spasm and pain (Hamilton, 2010).

With these existing literatures and researches, it can be implied that ice pack application is indeed widely used as a comfort measure and as a non-pharmacological management of pain.

The irritating effect of magnesium sulfate medication and the invasive application of the drug which is given intramuscularly cause injury to the affected site. Chemical mediators produce vasodilation. Vasodilation increases blood flow and brings phagocytes and other white blood cells to the area. Local inflammatory symptoms may occur such as redness, heat, swelling and pain. Cold application brings pain relief because it reduces inflammation. Ice decreases the conduction velocity of nociceptive nerve fibers, rendering the fiber incapable of transmitting the pain signal to the spinal cord. The client perceives the application area as numb. Ice pack applications to the surface of the body will also cause a contraction of the small blood vessels in that area.

This will have an immediate effect on reducing the flow of blood and other fluids through that area, and therefore help to reduce local swelling.


This study aimed to determine the effectiveness of ice pack application on pain reduction for patients receiving intramuscular Magnesium Sulfate administration.

Specifically, it seeks to answer the following objectives:

1. To determine the pain scores of the patients after the intramuscular administration of magnesium sulfate without ice pack application;

2. To determine the pain score of the patient receiving ice pack application fifteen minutes before and after intramuscular administration of magnesium sulfate; and,

3. To compare the pains cores of the patients receiving magnesium sulfate with and without ice pack application.


Ice pack application reduces pain in magnesium sulfate administration without any significant alteration in drug efficacy.


Research Design

One group pre-test post-test only design was employed to compare the pain scores before and after the injection of magnesium sulfate. Each subject served as her own control thereby minimizing extraneous variables that may affect the pain assessment. Though the design only had two observations, a third observation was conducted to serve as another baseline. This observation was conducted after an hour of the experiment. This was done to further determine the duration of pain reduction among the respondents.

Research Locale

The study was conducted only on the labor room (LR)/delivery room (DR) and Ward I (Obstetrics Ward) of Vicente Sotto Memorial Medical Center (VSMMC) in which it catered different obstetric clients in and out of the province of Cebu. The LR and DR was where the first dose of magnesium sulfate was usually administered for patients having the diagnosis of Severe Pre-eclampsia and Ward I was where the rest of the doses were administered.

Research Respondents

The research respondents included conscious and coherent patients in the Latent phase of labor, diagnosed with Severe Pre-eclampsia and receiving magnesium sulfate intramuscular therapy for the first time.

Research Sampling Techniques

In this study, a purposive sample of 30 was selected among patients diagnosed with severe preeclampsia, undergoing the latent phase of labor and receiving magnesium sulfate intramuscular therapy for the first time. The sample was isolated for intensive study.

Research Instruments

The instruments used in the research for data gathering were the following: the 0-10 Numeric Pain Rating Scale by McCaffery (1999), Seizure Monitoring Sheet, Reflex Scale and a reflex hammer.

The 0-10 Numeric Pain Rating Scale by McCaffery (1999) was adopted to measure the pain experienced by the patient during the administration of magnesium sulfate via intramuscular route. The scale grades 0 as no pain, 1-3 as mild pain, 4-6 as moderate pain, 7-9 as severe pain and 10 as the worst possible pain the patient could experience.

To use this 0-10 Numeric Pain Rating Scale by McCaffery (1999), the researcher let the patient be acquainted with the scale and instructed her to think of the pain she was feeling. Then, the researcher asked the patient, "On the scale of 0-10 what is the grade of the pain you are experiencing right now?" The patient's response was recorded.

The researchers made a Seizure Monitoring Sheet to be used in recording the pain score of the 30 respondents.

The Reflex Scale and the reflex hammer were utilized to determine the deep tendon reflexes of the patient. The Reflex scale grades 4+ as hyperactive, very brisk, rhythmic oscillations(clonus), 3+ as more brisk or active than normal, 2+ Normal, 1+ as less active than normal, and 0 as no response.

Research Data Gathering Procedures

Permission to conduct the study were obtained from the administrator and Ward Supervisor of the LR/DR of the Vicente Sotto Memorial Medical Center. Informed consent form was given to each of the selected respondents containing the full details of this study. After properly explaining the procedure and the selected respondents agreed to participate, the researchers progressed to the data collection proper. On the first dose, (W1) ice pack was not applied to the injection site before and after the intramuscular magnesium sulfate administration. The patient's pain score was obtained immediately after the injection through verbalization and with the use of the numeric pain rating scale. The patient was monitored for presence of seizures and the findings were recorded in the Seizure Monitoring Sheet. On the second dose, (0) ice pack was applied on the injection site 15 minutes before the administration of Magnesium sulfate and 15 minutes immediately after the administration. These ice packs were 6 inches in size, made of thick fabric filled with ice cubes to its full capacity. The patient's pain score was acquired immediately after the administration through verbalization and the use of the numeric pain rating scale. The patient was observed for presence of seizures and findings were recorded in the Seizure Monitoring Sheet. On the third dose/injection, (W2) the ice pack was not applied anymore but pain score was again reassessed. Table 1 below summarized the various observations of the respondents.

Statistical Analysis

The data gathered were tested for normality using Anderson-Darling test and showed a P-value of 0.028. Hence, parametric tests could not be done. The researchers used the non-parametric test alternative of paired t-test, which was Wilcoxon Signed Rank test.


The table presented W1, which had the highest mean pain score among the three followed by W2 and then O. Initially, W1 with its mean value of 6.95 could be rated as moderate pain.

Comparing W1 and W2 which were both without ice packs (refer to table 1), there was a difference of 0.53. Hence, the researchers affirmed that the decrease in pain score is due to the development of pain tolerance. If W1 and O were compared, there was a difference of 1.80. Using the first comparison as a basis, the difference indicated an accumulation of a decrease in pain due to cryotherapy and the development of pain tolerance. Comparing O and W2 there was a difference of -1.27. This showed that O, even on the second administration had a lower pain score than that of W2, which implied that cryotherapy played a huge role in the change in the pain scores.

This table showed the z-values and p-values of the different comparisons made using Wilcoxon Signed Rank test. Comparing W1 and W2, the test yielded a p-value of 0.009. Between W1 and O the p-value result was 0.000, similar to the comparison between O and W2. All p-values were less than 0.05 suggesting that each comparison of data was significant.All p-values were less than 0.05 suggesting that each comparison of data was significant. Changes in pain scores were attributed to the respondent's level of comfort from administration of the ice pack, which was supported by the Gate Control Theory.

The fundamental basis for this theory is the belief that psychological as well as physical factors guide the brain's interpretation of painful sensations and the subsequent response. One of these factors is counter stimulation in which ice pack application is used. Cryotherapy diverts pain perception on the response to cold stimulation (, 2007).


From the results drawn out from the study, the researchers concluded that cryotherapy was an effective intervention in decreasing the pain experienced during the intramuscular administration of magnesium sulfate. With the observations, it was reasonable to conclude that cryotherapy was the most plausible and perhaps the only explanation on pain alleviation.


Based on the conclusion above, the researchers had formulated the following recommendations:

1. To nursing practitioners, the application of ice pack may be included in the patient's plan of care provided that there is due consent for the given intervention.

2. To future researchers, further studies should be conducted to rule out other factors that affect pain perception of the patient such as labor pains, pain medications, surgical incisions and tolerance.

3. Other studies should be done for cryotherapy as comfort measure for intramuscular injections considering:

2.1. An increase in sample size

2.2. An extended length of time allotted for conducting the research



Beck, C.T., & Polit, D.F. 2008 Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philidelphia: Lippincott Williams and Wilkins

Dietz, D.BSN. 2009 Magnesium Sulfate Administration for Antepartum, Intrapartum and Postpartum Patients with Pre-Eclampsia. Retrieved October 26, 2010 from NursPandP/obs03_preeclampsia_032609.pdf accessed

Deglin, J.H. Pharm D 2008 Davis'Drug Guide for Nurses.11th Ed.. F.A. Davis Company, Philadelphia Euser, A. and Cipolla, M.

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Martinez D, 2008 Cryotherapy: A Review of the Literature. Retrieved October 6, 2010 from 2008 A guide to Post-injection Muscular pain. Retrieved October 22, 2010 from 2010 Ice and Heat Treatments for Injuries retrieved October 22, 2010 from http://

Premkumar K. 2004 The Massage Connection: Anatomy and Physiology. Philadelphia: Lippincott Williams & Wilkins

Semenovskaya, Z., 2010 Pregnancy, Preeclampsia. Emedicine. Retrieved September 22, 2010, from

Shuttleworth, Martyn 2009 Randomized Controlled Trials. Retrieved October 25, 2010 from Experiment Resources: trials.html

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Zeigler, Terry 2010 Using Cryotherapy to Reduce Pain and Swelling of Sports Injuries. Retrieved 2010 from


ORCID NO.:0000-0003-2080-2206


ORCID NO.:0000-0003-0657-1202


ORCID NO.:0000-0002-5142-9056


ORCID NO.:0000-0002-2015-9778


ORCID NO.:0000-0003-2269-0930


ORCID NO.:0000-0003-4357-1885


ORCID NO.:0000-0002-6549-8052

College of Nursing, Cebu Normal University

Table 1. Research observations in an experimental group

GROUP                                    Descriptions

Without Cryotherapy (W1)     W1 pain score reflected the mean pain
                           score of the respondents after the first
                           dose of magnesium sulfate administration
                                 without ice pack application.

With Cryotherapy (O)        O pain score was the mean pain score of
                                 the second dose with ice pack

Without Cryotherapy (W2)     W2 pain score reflected the mean pain
                           score of the respondents after the third
                           dose of magnesium sulfate administration
                                 without ice pack application.

Table 2. Mean Pain Scores and their Interpretation


Without Cryotherapy (W1)        6.95            moderate
With Cryotherapy (O)            5.15            moderate
Without Cryotherapy (W2)        6.42            moderate

* 0--no pain

1-3--mild pain

4-6--moderate pain

7-9--severe pain

10--worst pain

Table 3. Comparison of pain scores between

Pair-wise comparison   z-value   p-value

W1 vs W2                2.631     0.009
W1 vs O                 4.395     0.000
O vs W2                 3.788     0.000
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Article Details
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Author:Largo, Delight Grace; Ligtas, Caroline; Oppus, Kevin; Palileo, Krisha Marie; Suarez, Jesnel; Villega
Publication:Asian Journal of Health
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2013
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